Update on Imaging

f o r Ac u t e
Appendicitis
Nancy A. Parks, MD, Thomas J. Schroeppel, MD*

KEYWORDS
 Imaging  Acute  Appendicitis  CT  US  MRI

Acute appendicitis (AA) remains one of the most common surgical emergencies in the
United States with over 250,000 cases diagnosed each year. Lifetime risk of devel-
oping AA is 8.6% in men and 6.7% in women, with an overall appendectomy rate of
12% in men and 23% in women.1 The pathophysiology of AA is likely related to luminal
obstruction of the vermiform appendix. This condition leads to rising intraluminal pres-
sure, ischemia, and eventual perforation. Perforation increases the mortality rate of AA
from 0.0002% to 3% and increases the morbidity from 3% to 47%.2 This increase in
complications associated with advanced appendicitis and perforation has led to the
traditional surgical teaching that a negative appendectomy rate of 20% is acceptable
to balance the need for early diagnosis and avoid perforation. Current negative appen-
dectomy rates are lower because of the increasing use of imaging. A recent popula-
tion-based review found the rate of negative appendectomy to be 4.5% in those
with imaging and 9.8% in those with no imaging.3
Advances in imaging techniques over the past 20 years have changed the way sus-
pected AA is evaluated. Traditionally, the diagnosis was made based solely on the
history taking and physical examination. However, AA is known as the “great masquer-
ader” and has highly variable presentations and findings on examination. The presen-
tation of AA may be atypical, complicating the diagnosis and leading to delays in
treatment, prolonged hospitalization, and unnecessary surgery. Diagnostic accuracy
based on clinical findings alone is 80%. Based solely on history taking and physical
examination, men are diagnosed correctly 78% to 92% of the time, whereas women
are diagnosed correctly only 58% to 85% of the time.4 This difference is because in
women of childbearing age, the diagnosis of lower abdominal pain is difficult and
may be secondary to gynecologic conditions, such as ovarian disease or pelvic inflam-
matory disease. Clinicians are able to use a variety of imaging techniques in the evalu-
ation of suspected AA. In this article, ultrasonography (US), computed tomography

The authors have nothing to disclose.

Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue,
Suite 220, Memphis, TN 38163, USA
* Corresponding author.
E-mail address: tschroep@uthsc.edu

Surg Clin N Am 91 (2011) 141–154

doi:10.1016/j.suc.2010.10.017 surgical.theclinics.com
0039-6109/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
142 Parks & Schroeppel

(CT), and magnetic resonance imaging (MRI) are reviewed with respect to their accu-
racy in the diagnosis of AA and their ability to reduce negative appendectomy rates.

PLAIN RADIOGRAPHS

Plain abdominal radiographs are not routinely recommended for the evaluation of sus-
pected AA. If they are obtained in patients with acute abdominal pain, nonspecific
findings suggestive of AA may be evident. A calcified density in the right lower quad-
rant, or appendicolith, suggests the diagnosis of AA in the appropriate clinical setting
(Fig. 1). However, an appendicolith is visualized on plain radiographs in less than 5%
of patients with AA.4 Other findings on plain radiographs include abnormal gas
patterns in the right lower quadrant, a thickened appendix with irregular walls, or
a general haziness in the right lower quadrant. These findings are nonspecific and
present infrequently, greatly limiting their reliability in the diagnosis of AA.5
Perforated appendicitis (PA) with abscess can occasionally be demonstrated on
plain radiographs. Abscesses may appear as irregularly shaped, unilocular lucencies,
which occasionally contain gas. An abscess can cause an obstructive pattern on
radiograph, and in the correct clinical setting, PA should be considered as a possible
cause. Although a small amount of air may be released with PA, it is typically not
enough to be detected as pneumoperitoneum on plain radiographs.6

US

US has been used as a tool to aid in the diagnosis of AA since the 1980s. Over the last
30 years, advances in ultrasound technology and the graded compression technique

Fig. 1. Plain radiograph of the abdomen with arrow highlighting the calcified
appendicolith.
 Update on Imaging for Acute Appendicitis 143

have improved the ability to visualize the appendix. The graded compression tech-
nique involves applying steady, gradual pressure to the right lower quadrant in an
effort to collapse the normal bowel and eliminate normal bowel gas to visualize the
appendix. If AA is present, the appendix will be immobile, noncompressible, and thick-
ened with a diameter of greater than 6 to 7 mm (Figs. 2–4).7
US is operator dependent, and therefore, the reported sensitivity and specificity of
US in the diagnosis of AA is variable. US is most reliable in centers with considerable
experience using this imaging modality. In 2 recent meta-analyses reviewing the utility
of US, the sensitivity was reported as 78% and 83% and the specificity was 83% and
93%.8,9 Although both of these meta-analyses reported higher sensitivity and speci-
ficity data for CT than for US, a prospective trial comparing US with CT showed
that the diagnostic performance of both modalities was similar. In that trial, 94 adult
patients suspected of having AA underwent US and CT scanning. Findings on
US and CT were compared to clinical follow-up or surgical pathologic findings. The
diagnostic accuracy of US and CT were not significantly different, but there were
significantly more inconclusive findings with ultrasonography.10
Poortman and colleagues11 have developed an imaging pathway to minimize radi-
ation exposure from CT, while attempting to achieve a high accuracy in the diagnosis
of AA. In their prospective trial, 151 adults with suspected AA were evaluated. All
patients had an initial US. Of these patients, 79 (52%) were diagnosed with AA on
US and proceeded directly to appendectomy. The remaining 72 patients had a subse-
quent CT scan. CT diagnosed AA in 21 patients and found an alternative diagnosis in
12 patients and no cause for the abdominal pain in 39 patients. This strategy yielded
a negative appendectomy rate of 8%.
US has been particularly useful in the diagnosis of AA in children. Pediatric centers
have gained a large experience in US because of the concerns with childhood expo-
sure to ionizing radiation. A recent study of pediatric patients evaluated for acute
abdominal pain underscored the value of ultrasonography. Of the 622 patients, 152
were evaluated clinically and discharged. Another 81 patients were taken directly to
the operating room for appendectomy based on history taking and physical examina-
tion alone. Of these patients, 16 had a normal appendix on pathologic examination
(20% negative appendectomy rate). The remaining 389 patients had imaging per-
formed to evaluate their abdominal pain; 386 patients underwent US and 7 patients
underwent CT scans. Of the 389 patients, 137 were diagnosed with AA; only 3% of

Fig. 2. Sagittal US image of the appendix. Arrow highlights the thickened appendix.
144 Parks & Schroeppel

Fig. 3. Transverse US image of the appendix. Arrow highlights the thickened appendix.

this group had a negative appendectomy. No patients returned with a missed diag-
nosis of appendicitis. In this series, US was the primary imaging modality in children
with abdominal pain, yielding a lower rate of negative appendectomy than clinical
evaluation alone.12
US is also valuable in the diagnosis of AA in pregnant women. US is safe during all
trimesters of pregnancy and therefore is the initial imaging study of choice in pregnant
women with new-onset abdominal pain. US in pregnancy has a variable sensitivity,
ranging from 66% to 100%, but a good specificity of 95% to 96%.13 Because US is
safe, easy to obtain, and widely available, it is a good imaging study for pregnant
women with suspected AA. However, if the US result is negative or inconclusive, AA
cannot be excluded and further imaging studies are recommended.

Fig. 4. US of the appendix. (A) A thick-walled appendix inferior to the abdominal wall. (B)
Compression view demonstrating a noncompressible appendix. Arrows highlight the thick-
ened wall of the appendix.
 Update on Imaging for Acute Appendicitis 145

Advantages of US include the absence of ionizing radiation, low cost, and wide-
spread availability. In addition, it is noninvasive, safe, and quick to obtain and can
identify other causes of abdominal pain. A significant disadvantage of US is that it is
operator dependent, relying both on the US technician and the interpretation by the
radiologist. Also, if the appendix is not visualized, the study is inconclusive and no
decision can be made about the cause of the abdominal symptoms.

CT

CT is a highly accurate and effective modality for the evaluation of patients with sus-
pected AA. Modern helical CT scans have excellent resolution, are widely available,
and are operator independent. CT scans are easy to interpret and can provide signif-
icant information regarding alternative diagnoses. CT has been shown to have a sensi-
tivity of 90% to 100%, specificity of 91% to 99%, positive predictive value of 92% to
98%, and negative predictive value of 95% to 100%.14 This high accuracy is main-
tained in large university and rural community hospitals.15 However, in spite of the
widespread use and high accuracy of CT scanning, there is still considerable debate
regarding the true benefit of CT in patients with suspected AA.
CT diagnosis of AA is based on the appearance of a thickened, inflamed appendix
and surrounding signs of inflammation. In AA, the appendix is usually greater than
7 mm in diameter with circumferential wall thickening and mural enhancement, which
may give the appearance of a “target sign” on CT scan (Fig. 5).14 A calcified appen-
dicolith may be seen in up to 30% of cases (Fig. 6). Periappendiceal inflammation,
such as fat stranding, periappendiceal fluid, and clouding of the adjacent mesentery,
are common in AA. In PA, there may be a right lower quadrant abscess or extraluminal
gas (see Fig. 6; Figs. 7 and 8).16 If the appendix is not visualized and there are no find-
ings of inflammation in the right lower quadrant, the diagnosis of AA can be
excluded.17
Many possible protocols have been described for CT imaging in suspected AA. One
of the original articles to show a benefit with routine CT scanning in the evaluation of
suspected AA was done by Rao and colleagues18 using a limited appendiceal

Fig. 5. CT axial image demonstrating thick-walled appendix with stranding and inflamma-
tion. The arrow highlights the appendix with a “target sign.”
146 Parks & Schroeppel

Fig. 6. CT axial image demonstrating PA. The white arrow highlights a calcified appendico-
lith. The black arrow highlights an abscess cavity with a bubble of air adjacent to the
appendix.

Fig. 7. CT sagittal image of PA. Arrow highlights the abscess cavity containing a calcified
appendicolith.
 Update on Imaging for Acute Appendicitis 147

Fig. 8. CT coronal image of PA. Arrow highlights the abscess cavity containing a calcified
appendicolith.

protocol. In this study, 100 consecutive patients with suspected AA underwent

a limited scan through the region of the ileocecal valve after receiving enteric contrast
injected per rectum. The field of the scan included a 15-cm region centered around the
cecum as seen on the initial CT radiograph. The benefit of the limited scan is that it
requires approximately one-third the radiation of a full CT scan of the abdomen and
pelvis. Using this technique, the appendix was visualized in 94% of the patients.
The CT scan had an accuracy of 94%, and hence, the treatment plan in 59 patients
was changed, including preventing unnecessary appendectomy in 13 patients. A
cost analysis demonstrated an overall savings with the increased use of CT scanning
because of a decrease in the number of negative appendectomies and decreased
inpatient observation for equivocal cases.
There continues to be controversy regarding the optimal extent of the CT scan and
the need for contrast. A recent retrospective review of 100 consecutive, nonfocused
abdominal CT scans obtained for suspected AA concluded that limited appendiceal
CT scans should not be done because alternative diagnoses can be missed. The
investigators identified 7 patients with abnormalities in the upper abdomen, and 4 of
them required surgery. These findings would have been missed on a limited CT
scan. Based on these findings, the investigators concluded that full-abdomen and
pelvis CT scans should be obtained in the evaluation of suspected AA.19
There is also significant debate considering which, if any, contrast to administer with
CT scanning. In a series of 300 consecutive patients with suspected AA, CT scans of
the abdomen and pelvis were obtained without using any intravenous (IV) or enteric
contrast material to rapidly scan the abdomen. Radiological findings were compared
to clinical follow-up and surgical pathologic findings, yielding a sensitivity of 96%,
a specificity of 99%, and an accuracy of 97%. There were 5 false-negative results
148 Parks & Schroeppel

in this series, 3 of which occurred in thin, young women with little intraperitoneal fat.
The lack of intraperitoneal fat in a noncontrast CT scan was thought to lead to difficulty
in identifying the inflammatory process.20
Other investigators have reported on the value of contrast-enhanced CT scans. A
prospective randomized trial of 91 patients was done comparing the traditional
triple-contrast CT of the abdomen and pelvis with a limited appendiceal CT with rectal
contrast only. In this study, the limited scan with only rectal contrast was determined
to be superior to the triple contrast scan because it was more specific for AA, was well
tolerated by the patients, and quicker to perform.21 Other investigators have stated
that CT scans should be obtained with IV contrast to visualize the mild changes in
the appendix associated with early appendicitis.22
The final major area of debate is regarding which patients suspected of having AA
should have a CT scan before appendectomy. There are multiple articles in the liter-
ature, which argue against routine preoperative imaging of patients with suspected
AA.23–25 In these articles, the routine use of imaging has not been shown to decrease
the rate of negative appendectomy. In addition, concerns have been raised that
ordering routine imaging in the emergency department, before surgical consultation,
may actually delay the diagnosis and appropriate intervention in cases of AA.26 Early
surgical consultation and involvement of the surgeon while deciding to obtain a CT
scan may avoid an unnecessary delay.
Other studies have shown a benefit from preoperative imaging in suspected AA.
Naoum and colleagues27 showed that the development of a guideline to obtain
a CT in patients with an equivocal presentation decreased the rate of negative appen-
dectomy from 25% to 6%. Over the same time period, the use of preoperative CT scan
increased from 32% to 84% and the rate of PA remained unchanged. A review of
a large, prospectively gathered database of general surgical procedures in Washing-
ton State found the negative appendectomy rate to be 9.8% in patients with no preop-
erative imaging and only 4.5% in those who had a preoperative CT scan. This
difference was statistically significant.3 Based on these findings, CT scans seem to
have significant benefit in the evaluation of patients with suspected AA.

MRI

MRI has had little role in the evaluation of acute abdominal pain. However, increasing
concerns over the potentially hazardous effects of ionizing radiation associated with
CT have made MRI the study of choice to evaluate pregnant women and children
with symptoms of appendicitis and equivocal US findings.28
MRI has excellent resolution and has been shown to be highly accurate in diag-
nosing AA when based on standard criteria. A normal appendix is less than or equal
to 6 mm in diameter and filled with air or oral contrast material. MRI is considered
to provide positive results for AA when the appendix is enlarged (>7 mm), the appen-
diceal wall is thicker than 2 mm, or there are signs of inflammatory changes
surrounding the appendix, such as fat stranding, phlegmon, or abscess formation
(Figs. 9–11).29
Cobben and colleagues30 have evaluated the accuracy of MRI in diagnosing AA. In
this prospective study, 138 patients underwent both abdominal US and a limited, non-
contrast MRI through the region of the ileocecal valve. Overall, 62 patients were found
to have appendicitis, 42 had alternative diagnoses, and 34 did not have a cause for
abdominal pain identified. Their imaging results were compared to surgical patholog-
ical findings or clinical follow-up in the patients not requiring surgery. US had a sensi-
tivity of 88% and a specificity of 99%. MRI was highly accurate with a sensitivity of
 Update on Imaging for Acute Appendicitis 149

Fig. 9. MR scan with T1-weighted axial image of the abdomen in a gravid woman. Arrow
highlights the thickened appendix.

100%, specificity of 98%, positive predictive value of 98%, and negative predictive
value of 100%. MRI identified AA in 8 of the 36 patients with nondiagnostic US results.
The cost of obtaining an MRI in patients with equivocal US results was compared to
the cost of one day of inpatient hospital observation, and an overall cost savings
was found with MRI because patients could be discharged home safely after negative
MRI results.
Although MRI may be used in any patient with suspected AA, there is a special role
for MRI in pregnant women with new-onset abdominal pain. AA is the most common

Fig. 10. MR scan with T1-weighted coronal image of the abdomen in a gravid woman.
Arrow highlights the thickened appendix.
150 Parks & Schroeppel

Fig. 11. MR scan with T2-weighted coronal image of the abdomen in a gravid woman.
Arrow highlights the thickened appendix.

nonobstetric surgical emergency during pregnancy, complicating 1 in 766 births.31

AA can be difficult to diagnose during pregnancy because the history and clinical
presentation are often atypical. The location of abdominal pain associated with AA
is highly variable during pregnancy, with the appendix being displaced superiorly
and laterally by the enlarging uterus. Leukocytosis is a nonspecific finding during preg-
nancy.32 Traditional surgical teaching had been aggressive in recommending that
pregnant women with suspected AA undergo appendectomy because it was believed
that the risk of appendiceal perforation and subsequent fetal loss was greater than the
risk associated with negative appendectomy.33 A recent review found that negative
appendectomy rates were higher in pregnant women (23%) than in nonpregnant
women (18%). However, in this review negative appendectomy was associated with
fetal loss in 4% of cases and preterm delivery in 10% of cases. In comparison, rates
of fetal loss after appendectomy were 2% in simple appendicitis and 6% in compli-
cated appendicitis. Preterm delivery occurred in 4% of patients with simple appendi-
citis and 11% of patients with complicated appendicitis.34 These data underscore the
need for appropriate and timely diagnosis of AA in pregnancy.
MRI has been shown to reliably exclude the diagnosis of AA in pregnant women. In
a study by Pedrosa and colleagues,35 51 consecutive pregnant women suspected of
having AA underwent MRI. The patients were given oral contrast but no IV contrast.
Based on clinical follow-up and pathology results, this study showed that MRI had
a sensitivity of 100%, specificity of 93.6%, accuracy of 94%, and negative predictive
value of 100% in diagnosing pregnant women with AA.
MRI has many advantages. It is highly valuable in the imaging of pregnant women
and children because there is no exposure to ionizing radiation. Although MRI is
safe during pregnancy, no IV contrast should be used during pregnancy because
gadolinium is a category C drug and potentially teratogenic. However, noncontrast
 Update on Imaging for Acute Appendicitis 151

MRI provides detailed images, which usually provide the correct diagnosis. MRI is
operator independent and the results are highly reproducible. MRI is more useful
than US in obese patients and in patients with a retrocecal appendix, which is difficult
to visualize on US. Drawbacks of MRI are that it is more expensive than other imaging
modalities and not as widely available. The examination itself takes longer to perform
and may be degraded by motion artifact. There are concerns that, with the exception
of trained radiologists, other health care providers are not comfortable interpreting
MRI findings. As MRI becomes more available and faster protocols are developed,
these limitations may become less of an issue.36

PA

The imaging of advanced appendicitis merits special discussion because the preop-
erative recognition of PA or a well-formed abscess associated with AA may alter
treatment. US findings of PA are an irregular contour of the appendiceal wall or a peri-
appendiceal fluid collection. However, the appendix decompresses with perforation,
making PA more difficult to diagnose with US.2 Surrounding inflammatory changes
may be the most obvious findings on US after appendiceal perforation. A phlegmon
may be seen as a hypoechoic region with surrounding inflammation. An abscess is
seen as a fluid collection, possibly containing gas bubbles.14 Pickuth and colleagues37
obtained both CT and US in 120 consecutive patients suspected of having appendi-
citis and found that CT was superior to US in assessing periappendiceal inflammation.
On CT, 15% of the patient population had an identifiable abscess or phlegmon,
whereas on US, the abscess or phlegmon in only 9% of the patients was identified.
Horrow and colleagues38 studied the ability of CT to differentiate PA and AA. By
retrospectively reviewing the CT scans of 94 patients with appendicitis, the investiga-
tors were able to evaluate the sensitivity and specificity of the following findings,
abscess, phlegmon, extraluminal air, extraluminal appendicolith, and focal defect in
the appendiceal wall. Although the sensitivity for any one finding was low, using the
presence of any 1 of the 5 findings together increased the sensitivity to 94.9%. The
overall specificity was 94.5%. A similar study by Bixby and colleagues39 retrospec-
tively reviewed the CT scans of 244 patients with proven appendicitis. The specificity
for PA was as follows: abscess 99%, extraluminal gas 98%, and ileus 93%, but the
sensitivities were 34%, 35%, and 53%, respectively. Only the visualization of a defect
in the enhancing appendiceal wall has been shown to have both a high sensitivity
(95%) and specificity (96.8%) for PA.40

TYPHLITIS

Typhlitis, or neutropenic colitis, is an inflammatory condition of the cecum, ascending

colon, and occasionally the terminal ileum and appendix, which can easily be
mistaken for AA. Patients are typically immunocompromised, and imaging studies
show bowel wall thickening with intramural edema and surrounding inflammatory
changes. Radiographic studies showing colonic thickening greater than 0.3 cm, fluid
or fat stranding surrounding the colon, or edematous bowel wall are consistent with
typhlitis. AA and typhlitis can be differentiated by a clinical history of neutropenia as
well as imaging findings. The finding of symmetric thickened cecum and ascending
colon strongly suggests typhlitis; in addition, the extent of bowel involvement is usually
much greater in typhlitis than in AA.41
Both US and CT have been used in the evaluation of suspected typhlitis.
McCarville42 has evaluated 92 children being treated for cancer who developed typhli-
tis. In this study, US measurements of bowel wall thickness correlated with duration of
152 Parks & Schroeppel

Table 1
Statistics of imaging modalities for AA

Sensitivity (%) Specificity (%) PPV (%) NPV (%)

US8,9,13,14 66–100 83–96 91–94 89–97
CT14 90–100 91–99 92–98 95–100
MRI30,35,36 97–100 92–98 57–98 96–100

Abbreviations: NPV, negative predictive value; PPV, positive predictive value.

symptoms, whereas CT measurements did not, which may be because of overestima-

tion of bowel wall thickness on CT. Although CT may overestimate the edema of the
bowel wall, it provides additional information about the extent of inflammatory
changes in the right lower quadrant. Findings on CT associated with typhlitis include
pericolonic fluid collections, fat stranding, pneumatosis coli, or low-attenuation
regions within the colon wall indicative of possible necrosis.43

SUMMARY

Appendicitis is one of the most common surgical emergencies in the United States,
but it remains a diagnostic challenge in many patients who may present with atypical
clinical findings. Traditionally, negative appendectomy rates of approximately 20%
have been considered acceptable to avoid delayed diagnosis and increased rates
of PA. Imaging studies aid in the evaluation of suspected AA and reduction of negative
appendectomy rate. US is readily available and inexpensive, but it is highly operator
dependent and has lower overall sensitivity and specificity than CT or MRI. US is
a good screening test particularly in children, pregnant women, and centers with an
established US program. CT is widely available, is not operator dependent, and has
excellent accuracy in the diagnosis of appendicitis. However, care must be taken to
select patients with an equivocal clinical presentation and to involve the surgical
consultant early to yield the full benefits of CT scanning. CT scans are highly valuable
in the diagnosis of abdominal pain in women of childbearing age. Although CT scans
provide significant information about the inflammatory process associated with
appendicitis, only a CT scan result showing a defect in the appendiceal wall is diag-
nostic of PA. MRI is another highly accurate tool in evaluating suspected AA. The
drawbacks to MRI include its expense, longer time to obtain the study, and limited
availability compared with other imaging modalities. MRI is of the greatest value in
evaluating patients, such as children and pregnant women, who should not be
exposed to additional ionizing radiation and who have equivocal or nondiagnostic
findings on US. The respective sensitivities, specificities, and positive and negative
predictive values of US, CT, and MRI in the evaluation of suspected AA are seen in
Table 1. AA remains a disease that is diagnosed first and foremost with the initial
history and physical examination. If there is diagnostic uncertainty, then imaging
studies can improve negative appendectomy rates and diagnose alternatives,
including PA and typhlitis. CT remains the diagnostic study of choice for most patients
requiring imaging to aid in the diagnosis of AA.

REFERENCES

1. Addiss DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and
appendectomy in the United States. Am J Epidemiol 1990;132:910–25.
 Update on Imaging for Acute Appendicitis 153

2. Rybkin AV, Thoeni RF. Current concepts in imaging of appendicitis. Radiol Clin
North Am 2007;45:411–22.
3. Cuschieri J, Florence M, Flum DR, et al. The SCOAP Collaborative. Negative
appendectomy and imaging accuracy in the Washington State Surgical Care
and Outcomes Assessment Program. Ann Surg 2008;248:557–63.
4. Old JL, Dusing RW, Yap W, et al. Imaging for suspected appendicitis. Am Fam
Physician 2005;71:71–8.
5. Rypins EB, Evans DG, Hinrichs W, et al. Tc-99m-HMPAO white blood cell scan for
diagnosis of acute appendicitis in patients with equivocal clinical presentation.
Ann Surg 1997;226:58–65.
6. Baker SR. Acute appendicitis: plain radiographic considerations. Emerg Radiol
1996;3:63–9.
7. Prystowsky JB, Pugh CM, Nagle AP. Appendicitis. Curr Probl Surg 2005;42:
694–742.
8. Van Randen A, Bipat S, Zwinderman AH, et al. Acute appendicitis: meta-analysis
of diagnostic performance of CT and graded compression US related to preva-
lence of disease. Radiology 2008;249:97–106.
9. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appen-
dicitis in children and adults? A meta-analysis. Radiology 2006;241:83–94.
10. Keyzer C, Zalcman M, De Maertelaer V, et al. Comparison of US and unenhanced
multi-detector row CT in patients suspected of having acute appendicitis. Radi-
ology 2005;236:527–34.
11. Poortman P, Oostvogel HJM, Bosma E, et al. Improving diagnosis of acute
appendicitis: results of a diagnostic pathway with standard use of ultrasonog-
raphy followed by selective use of CT. J Am Coll Surg 2009;208:434–41.
12. Hernandez JA, Swischuk LE, Angel CA, et al. Imaging of acute appendicitis: US
as the primary imaging modality. Pediatr Radiol 2005;35:392–5.
13. Patel SJ, Reede DL, Katz DS, et al. Imaging the pregnant patient for nonobstetric
conditions: algorithms & radiation dose considerations. Radiographics 2007;
27(6):1705–22.
14. Birnbaum BA, Wilson SR. Appendicitis at the millennium. Radiology 2000;215:
337–48.
15. Holloway JA, Westerbuhr LM, Chain J, et al. Is appendiceal computed tomog-
raphy in a community hospital useful? Am J Surg 2003;186:682–4.
16. Whitley S, Sookur P, McLean A, et al. The appendix on CT. Clin Radiol 2009;64:
190–9.
17. Brown MA. Imaging acute appendicitis. Semin Ultrasound CT MR 2008;29:
293–307.
18. Rao PM, Rhea JT, Novelline RA, et al. Effect of computed tomography of the
appendix on treatment of patients and use of hospital resources. N Engl J Med
1998;338:141–6.
19. Kamel IR, Goldberg SN, Keogan MT, et al. Right lower quadrant pain and sus-
pected appendicitis: nonfocused appendiceal CT—review of 100 cases. Radi-
ology 2000;217:159–63.
20. Lane MJ, Liu DM, Huynh MD, et al. Suspected acute appendicitis: nonenhanced
helical CT in 300 consecutive patients. Radiology 1999;213:341–6.
21. Mittal VK, Goliath J, Sabir M, et al. Advantages of focused helical computed
tomographic scanning with rectal contrast only vs triple contrast in the diagnosis
of clinically uncertain acute appendicitis. Arch Surg 2004;139:495–500.
22. Birnbaum BA, Jeffrey RB. CT and sonographic evaluation of acute right lower
quadrant abdominal pain. AJR 1998;170:361–71.
154 Parks & Schroeppel

23. Perez J, Barone JE, Wilbanks TO, et al. Liberal use of computed tomography
scanning does not improve diagnostic accuracy in appendicitis. Am J Surg
2003;185:194–7.
24. Vadeboncoeur TF, Heister RR, Behling CA, et al. Impact of helical computed
tomography on the rate of negative appendicitis. Am J Emerg Med 2006;24:43–7.
25. Morris KT, Kavanagh M, Hansen P, et al. The rational use of computed tomog-
raphy scans in the diagnosis of appendicitis. Am J Surg 2002;183:547–50.
26. Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not
improve and may delay the diagnosis and treatment of acute appendicitis.
Arch Surg 2001;136:556–62.
27. Naoum JJ, Mileski WJ, Daller JA, et al. The use of abdominal computed tomog-
raphy scan decreases the frequency of misdiagnosis in cases of suspected
appendicitis. Am J Surg 2002;184:587–90.
28. Singh A, Danrad R, Hahn PF, et al. MR imaging of the acute abdomen and pelvis:
acute appendicitis and beyond. Radiographics 2007;27:1419–31.
29. Tkacz JN, Anderson SA, Soto J. MR imaging in gastrointestinal emergencies.
Radiographics 2009;29:1767–80.
30. Cobben L, Groot I, Kingma L, et al. A simple MRI protocol in patients with clini-
cally suspected appendicitis: results in 138 patients and effect on outcome of
appendectomy. Eur Radiol 2009;19:1175–83.
31. Andersen B, Nielsen TK. Appendicitis in pregnancy: diagnosis, management and
complications. Acta Obstet Gynecol Scand 1999;78:758–62.
32. Gjelsteen AC, Ching BH, Meyermann MW, et al. CT, MRI, PET/CT, and ultrasound
in the evaluation of obstetric and gynecologic patients. Surg Clin North Am 2008;
88:361–90.
33. Freeland M, King E, Safcsak K, et al. Diagnosis of appendicitis in pregnancy. Am
J Surg 2009;198:753–8.
34. McGory ML, Zingmond DS, Tillou A, et al. Negative appendectomy in pregnant
women is associated with a substantial risk of fetal loss. J Am Coll Surg 2007;
205:534–40.
35. Pedrosa I, Levine D, Eyvazzadeh AD, et al. MR imaging evaluation of acute
appendicitis in pregnancy. Radiology 2006;238:891–9.
36. Lam M, Singh A, Kaewlai R, et al. Magnetic resonance of acute appendicitis:
pearls and pitfalls. Curr Probl Diagn Radiol 2008;37:57–66.
37. Pickuth D, Heywang-Kobrunner SH, Spielmann RP. Suspected acute appendi-
citis: is ultrasonography or computed tomography the preferred imaging tech-
nique? Eur J Surg 2000;166:315–9.
38. Horrow MM, White DS, Horrow JC. Differentiation of perforated from nonperfo-
rated appendicitis at CT. Radiology 2003;227:46–51.
39. Bixby SD, Lucey BC, Soto JA, et al. Perforated versus nonperforated acute
appendicitis: accuracy of multidetector CT detection. Radiology 2006;241:780–6.
40. Tsuboi M, Takase K, Kaneda I, et al. Perforated and nonperforated appendicitis:
defect in enhancing appendiceal wall—depiction with multi-detector row CT.
Radiology 2008;246:142–7.
41. Hoeffel C, Crema MD, Belkacem A, et al. Multi-detector row CT: spectrum of
disease involving the ileocecal area. Radiographics 2006;26:1373–90.
42. McCarville MB. Evaluation of typhlitis in children: CT versus US. Pediatr Radiol
2006;36:890–1.
43. Yu J, Fulcher AS, Turner MA, et al. Helical CT evaluation of acute right lower quad-
rant pain: part II, uncommon mimics of appendicitis. AJR 2005;184:1143–9.